Tag: NY State EPIC

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Medicare Part C Medicare Advantage Part D Prescription Drug

What If I Missed the Medicare AEP Deadline?

This year’s Medicare Annual Enrollment Period (October 15 through December 7) was a busy time and we are grateful for the hundreds of individuals and couples who permitted our team of agent advisors to help with their 2026 Part C Medicare Advantage plan selection. (The December 7 deadline does not apply to a Medicare Supplement plan selection.)

Q: But I missed that deadline. Is there another option for me to choose a new plan for 2026?
A: Possibly. Some Medicare participants are eligible for what is called a Special Enrollment Period during which you can make a change to your Medicare Advantage Plan.

Q: Am I eligible for a Special Enrollment Period?
A: Let’s look at some special situations that may apply to you. If one does, you can make changes to your Medicare Advantage plan coverage outside of the normal Annual Enrollment Period:

  • Has your 2025 Medicare Advantage Plan been discontinued? If so, you have some additional time to enroll in new coverage for January 1. One of our agents can assist you with finding a plan that matches your providers, medications and budget.
  • Do you belong to New York State EPIC?  If so, you have one Special Enrollment Period per calendar year to enroll in a new Medicare Advantage or Part D prescription drug plan. [Download the EPIC application here.] 
  • Are you a veteran? Many veterans may not be aware of a valid Special Election Period available by having their prescriptions filled through the Veterans Administration (VA.) Veterans can use that Special Enrollment Period to enroll in a “MA only” plan – a Medicare Advantage plan with no drug benefits.  Click here for more information on MA Only plans.
  • You may be eligible for Social Security Extra Help – Eligibility for this program is based on your income and assets. Extra Help subsidizes part or all of your plan’s premium, drug deductible and reduce prescription co-payment. With Extra Help, you may be able to make changes to your coverage one time during each of these periods:
    • January – March
    • April – June
    • July – September

Q: Do any of these Special Circumstances apply to Medicare Supplement plans?
A: No. However three states, including New York and Massachusetts, do require Medicare Supplement plan insurers to offer policies to Medicare beneficiaries age 65 and older through continuous open enrollment, with guaranteed issue rights  throughout the year.

That means if you want to drop a Medicare Advantage plan (which includes prescription drug coverage) and return to Original Medicare with a Medicare Supplement plan; you need a Special Enrollment Period to add the third piece, your Part D prescription drug coverage.

Q:  I’m not sure of my eligibility status, can you help me with my questions?
A: Yes. Simply use the form below and send a note to an agent advisor or call (518) 346-2115. We’ll discuss your options by telephone or Zoom web conference. And, during your Special Enrollment Period, we may be able to identify a Medicare Advantage, Medigap or Prescription Drug Plan more suited to your needs – even though the December 7 deadline has passed.

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Medicare Medicare A & B Medicare supplement Part C Medicare Advantage Part D Prescription Drug

About the 2026 Medicare Annual Enrollment

Annual Enrollment Period

The Medicare Annual Enrollment Period, from October 15th through December 7th, is when Medicare beneficiaries can enroll in or change their Medicare Advantage (Part C) or Medicare Prescription Drug (Part D) plan to take effect January 1.

Some Important Tips to Consider if you are now enrolled in a Medicare Advantage (Part C) Plan:
  • You can leave your Medicare Advantage plan and enroll in another Medicare Advantage plan offered in your county. [We offer several]
  • Even if you decide to stay with your current Medicare Advantage plan, make sure your doctors and preferred hospitals are still in your network, especially if your plan is a HMO. 
  • You can leave Medicare Advantage and return to Original Medicare and purchase a Medicare Supplement (aka Medigap) policy. For New York State residents, acceptance is guaranteed and the continuous coverage transfer means no pre-existing condition limitations apply.
Some Important Tips to Consider if you HAVE ORIGINAL MEDICARE AND a Medicare SUPPLEMENT Plan:
  • The Annual Enrollment Period applies to your Part D drug plan only.
  • New York State residents can change their Medicare Supplement plan at any time of the year and without medical underwriting. An example could be changing from one company to another or changing from one plan (Plan F, Plan G, Plan N or High Deductible) to another. 
  • You can leave your Medicare Supplement (Medigap) plan and join a Medicare Advantage plan during the Annual Enrollment Period. There is no underwriting to move to a Medicare Advantage plan. You will be automatically accepted as long as your permanent address is within the coverage area.
  • Unless your prescription drugs are covered through the Veterans Administration, most individuals with Original Medicare and a Medicare Supplement plan also add a Medicare Part D prescription drug plan. We recommend updating your medication list and confirming – through your personal account at medicare.gov – which Part D drug plans will cover your prescriptions at the lowest annual out of pocket costs – that includes premium, deductible and prescription copay costs.

Our team of licensed, independent and certified agent advisors, from Long Island to the North Country, offer a no-obligation complimentary consultation to help you compare Medicare plans in your coverage area.

So, reach out to local agent by phone, an online note or book an appointment directly to his or her calendar and learn more about your Medicare plan options.

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Medicare Part D Prescription Drug

The New Law and Medicare Part D

The US House and Senate has passed a bill (H.R. 5376 titled Inflation Reduction Act of 2022) which includes some important changes to the Medicare Part D prescription drug coverage.

Some of these changes take effect next year and others over the next several years. I have looked over the text, studied several analysis and have summarized below the 4 changes most likely to Medicare beneficiaries:

  1. Insulin – Effective 2023
  2. Adult Vaccines – Effective 2023
  3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
  4. Medicare to Negotiate Part D and Part B Drug Prices – Effective 2026

Please note: If you are receiving Part D financial assistance through state Medicaid or the Social Security Extra Help program, your benefits may already exceed what is becoming effective in this new bill. Also, if your medications are covered through your VA benefits, you may want to compare these new benefits to what VA covers and compare your options in the years ahead.

1. Insulin – Effective 2023 Beginning in 2023, for Medicare Part D beneficiaries who need insulin, monthly out-of-pocket costs will be capped at $35, and starting in 2026, the cap would be $35 or 25% of the negotiated price if that is lower. And insulin products will no longer subject to a Part D deductible.

2. Adult Vaccines – Effective 2023
Beginning in 2023, Medicare Part D cost-sharing will be eliminated for adult vaccines that are recommended by the Advisory Committee on Immunization Practices. For most clients, the most significant change will be the new $0 Part D copay for the two shot Shingles vaccine, previously covered through Part D however frequently subject to a deductible and higher Tier copay.

3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
For clients with drug costs placing them in the “Coverage Gap” (aka Donut Hole) and Catastrophic Coverage Phase, this change will be very welcomed although phased in over time.

In 2024, that 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level in Medicare will end. As you may imagine, 5% on some of those expensive drugs that cost thousands monthly can be a lot of money. That ends in 2024.

And in 2025 your Medicare Part D out-of-pocket spending will be capped at $2,000 a year, increased to $2,100 in 2026.

4. Medicare to Negotiate Part D and Part B Drug Prices
CMS (Centers for Medicare & Medicaid Services) will be authorized and required to negotiate maximum prices for brand-name drugs that do not have other generic equivalents and that account for the greatest Medicare spending.

There is not yet an official, publicly available list of drugs that Medicare plans to target for negotiations. However Kaiser Family Foundation reports how just a handful of drugs represent the lion’s share of Medicare drug costs. Some likely candidates, based on how much Medicare spent on them in 2020: Eliquis, Xarelto and Januvia.

Today, those brand name drugs that do not have generic equivalents and represent the greatest cost are typically listed as Tier 4 or Tier 5 specialty medications under Medicare Part D coverage.

CMS will begin by negotiating the prices of 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and each year thereafter. The negotiations would apply first to drugs people get at the pharmacy (Part D), but in the later two years, drugs administered in doctors’ offices (Part B) could also be covered.

If you have any questions or would like for me to review with you your plan benefits please schedule a telephone or Zoom conference convenient for you and direct to my calendar, call us at (518) 346-2115 or send a note to one of our licensed and carrier certified agents closest to you:

Contact Us
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Medicare Permission to Contact (PTC) guidelines require agents to obtain explicit, documented consent from a beneficiary before initiating any unsolicited outreach. The PTC consent expires after 9 months.
1
Your State *
My Licensed Sales Agent (in alphabetical order) *
Are You an Existing Client? *
This helps us prepare for our conversation
How Did You Hear About Us? *

 

Categories
Part D Prescription Drug Uncategorized

Part D Late Enrollment Penalty

Q: “Dan, I just received a letter stating I will have to pay a Part D late enrollment penalty next year for not having a drug plan during the months of February through December, 2017. What’s this all about?”

A: “Sam, after you turned 65 in October 2016 you had individual coverage with prescription drug benefits through January 2017. Now you’re enrolling in a Medicare Advantage plan with Part D coverage, effective January 2018. For those 11 months, February through December, that you went without drug coverage Medicare will impose a penalty for the late enrollment.”

Again, why do I owe a late enrollment penalty?

If, for any continuous period of 63 days or more after your Initial Enrollment Period is over you go without one of the following, you will have a penalty added to your Medicare Part D premium:

  • A Medicare Prescription Drug Plan (Part D)
  • A Medicare Advantage Plan (Part C) (HMO or PPO) with prescription drug coverage.
  • Creditable prescription drug coverage (a drug plan that pays at least as much as the Medicare standard – most often provided through an employer or the individual insurance exchange.)

 

How does Medicare calculate the late enrollment penalty?

The penalty is based on multiplying two factors.

  1. Medicare calculates 1% of the “national base beneficiary premium” ($35.63 in 2017; $35.02 in 2018) which for 2018 will be $.35
  2. Medicare determines the number of full, uncovered months you didn’t have Part D or creditable coverage. In the above instance, that was 11 months.
  3. The $.35 is then multiplied by the number of months. In our example of 11, that equals $3.85
  4. The monthly penalty is rounded to the nearest $.10 (the example would then be rounded to $3.90) and added to your monthly Part D premium.

Will the late enrollment penalty change?

Yes, annually.  When Medicare determines the national base beneficiary premium has changed, as in $35.63 in 2017 to $35.02 in 2018, the late enrollment penalty amount will be recalculated.

Do I pay the late enrollment penalty through Social Security?

No.  The penalty, rounded to the nearest $.10 is added to your Part D premium and collected by your private insurance company

 

Source: https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html

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